Health Care, the Marshall Islands, and Free Association

Posted April 2, 2017

Free Association is one of the options in the upcoming status vote in Puerto Rico. It is included as a possible form of independence. Since Puerto Rico has been a territory of the United States for more than a century and was a colony of Spain for four centuries before that, it may be difficult for voters to predict how the different status options will work out for Puerto Rico.

As far as statehood is concerned, Puerto Rico can look at the 50 states and get a fairly clear idea of what it’s like to be a state. We can see how a tropical territory like Hawaii fares as a state, how a Spanish-speaking territory like New Mexico did in its transition to statehood, and how a financially strapped territory like Alaska benefited from statehood. Statehood isn’t much of a mystery.

Independence may be less certain, but there are former U.S. territories which are now independent nations: Cuba and the Philippines. They might give an indication of how independence could work for Puerto Rico.

There are also nations which currently have Compacts of Free Association with the United States, and examining these may be a good way to get a sense of how Free Association might work. One is the Republic of the Marshall Islands (RMI). We’ve seen the overall terms of the COFA and what it means for Marshallese residents of the U.S. as well as those living in the Marshall Islands.

Health care is a particular issue for RMI, and as such deserves further exploration.

The Marshall Islands were part of the Pacific Islands Trust Territory administered by the United States following the second World War. In 1986, the RMI negotiated a Compact of Free Association with the United States. The agreement was to last for 15 years.

Bikini and Enewetak Atolls, both in the Marshall Islands, were used for nuclear testing after World War II. Between 1946 and 1958, 66 nuclear weapons tests took place. The Marshallese people were relocated from those atolls to other parts of the islands, but a recent study concluded that people received radiation doses of as much as 1,000 mGy (mGy, or megagray, is the standard unit of measurement of radiation absorbed). By comparison, normal levels of exposure in the U.S. are around 1 mGy. Some residents had acute radiation sickness, but many seemed well at the time or soon after. The long term effects of radiation were not well understood at that time.

In a recent study, the National Cancer Institute concluded that people living in the Marshall Islands at the time of the nuclear testing had an increased chance of suffering from cancer. There is also evidence that women who grew up in RMI had children with lower birth weights and lessened immunity to disease.

The first Compact of Free Association for the Marshall Islands included a Nuclear Claims Tribunal, but the updated COFA of 2003 did not. This means that there is no longer any mechanism for survivors of the nuclear testing, or their children, to ask for compensation. There are political efforts underway to help the military veterans who were exposed to radiation during the cleanup of the islands, but no related efforts for its residents, and compensation for the Marshallese has still not been paid in full as the Nuclear Claims Tribunal was not fully funded by Congress.

Senator Al Franken posted about the veteran’s health care needs on his Facebook page recently, but did not mention the Marshallese:

The “Atomic Veterans” cleaned up nuclear testing sites in the Marshall Islands during the late 1970s, but despite their health and lives being put at risk, these veterans are often forced to pay out of pocket for expensive medical procedures and care because the VA does not recognize that they were exposed to high levels of radiation.

This bipartisan measure, named after the late Congressman Mark Takai who helped me introduce the bill last year, would ensure that veterans who participated in the cleanup of these testing sites receive the benefits they deserve and should have received long ago. I urge all of my colleagues to honor our veterans by passing this bill.

Under the first COFA, the victims of radiation were treated in the Marshall Islands, and sent to hospitals on the U.S. mainland for treatment when necessary. The referrals to stateside hospitals ended with the new COFA. Reports on medical care following the nuclear testing make it clear that the Marshallese did not entirely trust the medical personnel.

Testing of Bikini Atoll over the years continues to show that the atoll must still be considered uninhabitable if people living there might eat locally-produced food. Otherwise, the U.S. government concluded by the end of the 20th century that the Marshall Islands were safe for human beings.

That’s not the end of the story, though. The war was unsettling for the people of the Marshall Islands, of course, since there was active combat on the islands. The military activities of the U.S. following the war continued that disruption. People were relocated not only for the nuclear testing, but also for the building of what is now the Ronald Reagan Ballistic Missile Defense Site of the Army’s Space and Missile Defense Command at Kwajalein Atoll.

The disruption of the traditional Marshallese way of life was profound. Crowding and urban poverty led to the spread of infectious diseases such as tuberculosis and leprosy. Another element was aid in the form of canned meat, white rice, and other relatively low nutrition foods. The traditional diet of fish and copra (a coconut product) has by now been replaced almost entirely by imported processed foods — a study conducted from 2007 to 2013 found that the diet of people in the Marshall Islands consists almost entirely of Spam, canned fish, and white rice. While the innovation of canned foods is often discussed apart from the nuclear testing, it is clear that eating the local food was in at least some cases dangerous because of radiation, and that may have contributed to the change in eating habits. 90% of RMI food is now imported.

The Marshall Islands are plagued by Zika, dengue, and other tropical diseases, as well as the urban diseases brought into the island.

Health issues among Marshallese in the States are serious, too. Nearly half the adult population suffers from adult-onset diabetes. The infant mortality rate is five times that of the average U.S. population. Both chronic and infectious diseases are unusually high as well. Acoholism and suicide rates are also high.

Since they are not U.S. citizens, the Marshallese are not eligible for Medicaid, no matter where they live. In the largest mainland Marshallese community, in Springdale, Arkansas, two thirds of the Marshallese residents have health insurance and there are free clinics available. Nonetheless, health professionals in the U.S. say that Marshallese patients don’t visit a doctor until they are already very sick. While doctors often attribute this to strong family structures which cause the Marshallese people to try to solve problems within their family circle before looking to outsiders, it seems possible that distrust of medical professionals may linger in this community.

According to researchers, the Marshallese see diabetes, which is extremely prevalent among Marshallese people both in RMI and in the States, as inevitable. Marsallese diabetics often do not follow the recommendations given by doctors, and may not understand the effects of their dietary choices on their health. While this is seen as a patient education issue by health professionals, it seems possible that the legacy of the nuclear testing is part of the problem.

People who have learned that locally grown food is dangerous, that medical professionals are untrustworthy, and that their health can be affected quite suddenly by things they do not understand are not ideal candidates for effective health management through lifestyle choices. It seems likely that the general poor health of Marshall Islanders may be the result not only of the radiation from nuclear testing, but also of the cultural disruption that took place. It is clear that the U.S. is not providing adequate response to the health problems which may be entertwined with the history of the Marshall Islands.

The Compact of Free Association between the Marshall Islands and the United States took place decades after the nuclear testing ended and the United States had taken the position that the islands had been restored to safety. But the agreed-upon funds were not all actually provided by Congress before the COFA expired. New funds were negotiated in the new COFA, but these funds have not been provided by Congress, and the new COFA is much weaker than the original.

RMI was never a territory of the United States, as Puerto Rico is. Some supporters of Free Association for Puerto Rico assume that this will make a big difference in negotiations. But what the COFA documents call the “special relationship” of the Marshall Islands and the United States, makes it seem reasonable that the Marshall Islands should receive reparations from the U.S. far in excess of what has actually been provided. Compacts of Free Association are negotiated. Puerto Rico may want to consider the experience of the Marshall Islands before choosing that option.